Ice-Breaker Form Survey

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* 1. How easy or difficult was it to access, download and print the Ice-Breaker Form?

Very easy

Somewhat easy

Neither easy nor difficult

Somewhat difficult

Very difficult

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* 2. How easy or difficult was it to answer the questions in the Ice-Breaker Form?

Very easy

Somewhat easy

Neither easy nor difficult

Somewhat difficult

Very difficult

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* 3. What could have been done to improve your experience of downloading, printing and completing the Ice-Breaker Form?

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* 4. Who did you discuss the details you'd written on the Ice-Breaker form with?

General Practitioner (GP)

Mental Health specialist or therapist

Community Matron

Other medical professional

Representative from Social Services (Locality Team, Safeguarding Team, Family Support Services, etc)

Member of the Emergency Services (Police, Fire Service, Ambulance Service)

Professional Hoarding Practitioner or Professional Organiser

Other (please specify)

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* 5. Before you discussed the Ice-Breaker with the person, how much did you trust them you to make decisions that are in your best interests?

A great deal

A lot

A moderate amount

A little

Not at all

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* 6. How well did the person actively listen to your needs?

Extremely well

Very well

Somewhat well

Not so well

Not at all well

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* 7. How well did the person answer your questions?

Extremely well

Very well

Somewhat well

Not so well

Not at all well

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* 8. What treatment options did the person suggest?

Cognitive Behavioural Therapy (CBT)?

Other therapy?

Support from social care (Social Services)?

Practical support from a Professional Hoarding Practitioner or Professional Organiser?

Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service

Attend a Hoarding Support Group?

Attend another Support Group?

Phone a Helpline?

Emotional Freedom Technique (EFT)?

Other (please specify)

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* 9. How well did the person explain your treatment options?

Extremely well

Very well

Somewhat well

Not so well

Not at all well

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* 10. How well did the person explain your follow-up care?

Extremely well

Very well

Somewhat well

Not so well

Not at all well

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* 11. How satisfied or dissatisfied were you with the amount of time the person spent with you addressing your needs?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

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* 12. Overall, how satisfied or dissatisfied were you with the conversation you had with the person about what you'd written on the Ice-Breaker Form?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

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* 13. Overall, how would you rate the care you received from the person you spoke with about the Ice-Breaker Form?

Excellent

Very good

Good

Fair

Poor

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* 14. AFTER you discussed the Ice-Breaker with the person, how much did you trust them you to make decisions that are in your best interests?

A great deal

A lot

A moderate amount

A little

Not at all

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* 15. What could have been done to improve your experience of discussing what you'd written on the Ice-Breaker Form with the person you spoke with?

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* 16. Overall, how would you rate the usefulness of the Ice-Breaker Form to start a conversation about the issues you wrote on the form?

Excellent

Very good

Good

Fair

Poor

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* 17. How satisfied or dissatisfied were you with the treatment options you tried?

	Very satisfied	Somewhat satisfied	Neither satisfied nor dissatisfied	Somewhat dissatisfied	Very dissatisfied	N/A
Cognitive Behavioural Therapy (CBT)?	Cognitive Behavioural Therapy (CBT)? Very satisfied	Cognitive Behavioural Therapy (CBT)? Somewhat satisfied	Cognitive Behavioural Therapy (CBT)? Neither satisfied nor dissatisfied	Cognitive Behavioural Therapy (CBT)? Somewhat dissatisfied	Cognitive Behavioural Therapy (CBT)? Very dissatisfied	Cognitive Behavioural Therapy (CBT)? N/A
Other therapy?	Other therapy? Very satisfied	Other therapy? Somewhat satisfied	Other therapy? Neither satisfied nor dissatisfied	Other therapy? Somewhat dissatisfied	Other therapy? Very dissatisfied	Other therapy? N/A
Support from social care (Social Services)?	Support from social care (Social Services)? Very satisfied	Support from social care (Social Services)? Somewhat satisfied	Support from social care (Social Services)? Neither satisfied nor dissatisfied	Support from social care (Social Services)? Somewhat dissatisfied	Support from social care (Social Services)? Very dissatisfied	Support from social care (Social Services)? N/A
Practical support from a Professional Hoarding Practitioner or Professional Organiser?	Practical support from a Professional Hoarding Practitioner or Professional Organiser? Very satisfied	Practical support from a Professional Hoarding Practitioner or Professional Organiser? Somewhat satisfied	Practical support from a Professional Hoarding Practitioner or Professional Organiser? Neither satisfied nor dissatisfied	Practical support from a Professional Hoarding Practitioner or Professional Organiser? Somewhat dissatisfied	Practical support from a Professional Hoarding Practitioner or Professional Organiser? Very dissatisfied	Practical support from a Professional Hoarding Practitioner or Professional Organiser? N/A
Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service Very satisfied	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service Somewhat satisfied	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service Neither satisfied nor dissatisfied	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service Somewhat dissatisfied	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service Very dissatisfied	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service N/A
Attend a Hoarding Support Group?	Attend a Hoarding Support Group? Very satisfied	Attend a Hoarding Support Group? Somewhat satisfied	Attend a Hoarding Support Group? Neither satisfied nor dissatisfied	Attend a Hoarding Support Group? Somewhat dissatisfied	Attend a Hoarding Support Group? Very dissatisfied	Attend a Hoarding Support Group? N/A
Attend another Support Group?	Attend another Support Group? Very satisfied	Attend another Support Group? Somewhat satisfied	Attend another Support Group? Neither satisfied nor dissatisfied	Attend another Support Group? Somewhat dissatisfied	Attend another Support Group? Very dissatisfied	Attend another Support Group? N/A
Phone a Helpline?	Phone a Helpline? Very satisfied	Phone a Helpline? Somewhat satisfied	Phone a Helpline? Neither satisfied nor dissatisfied	Phone a Helpline? Somewhat dissatisfied	Phone a Helpline? Very dissatisfied	Phone a Helpline? N/A
Emotional Freedom Technique (EFT)?	Emotional Freedom Technique (EFT)? Very satisfied	Emotional Freedom Technique (EFT)? Somewhat satisfied	Emotional Freedom Technique (EFT)? Neither satisfied nor dissatisfied	Emotional Freedom Technique (EFT)? Somewhat dissatisfied	Emotional Freedom Technique (EFT)? Very dissatisfied	Emotional Freedom Technique (EFT)? N/A

Other (please specify)

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* 18. How long did you persevere with the treatment options?

	1 session	2-5 sessions	6-10 sessions	11-20 sessions	More than 20 sessions	Still ongoing	N/A
Cognitive Behavioural Therapy (CBT)?	Cognitive Behavioural Therapy (CBT)? 1 session	Cognitive Behavioural Therapy (CBT)? 2-5 sessions	Cognitive Behavioural Therapy (CBT)? 6-10 sessions	Cognitive Behavioural Therapy (CBT)? 11-20 sessions	Cognitive Behavioural Therapy (CBT)? More than 20 sessions	Cognitive Behavioural Therapy (CBT)? Still ongoing	Cognitive Behavioural Therapy (CBT)? N/A
Other therapy?	Other therapy? 1 session	Other therapy? 2-5 sessions	Other therapy? 6-10 sessions	Other therapy? 11-20 sessions	Other therapy? More than 20 sessions	Other therapy? Still ongoing	Other therapy? N/A
Support from social care (Social Services)?	Support from social care (Social Services)? 1 session	Support from social care (Social Services)? 2-5 sessions	Support from social care (Social Services)? 6-10 sessions	Support from social care (Social Services)? 11-20 sessions	Support from social care (Social Services)? More than 20 sessions	Support from social care (Social Services)? Still ongoing	Support from social care (Social Services)? N/A
Practical support from a Professional Hoarding Practitioner or Professional Organiser?	Practical support from a Professional Hoarding Practitioner or Professional Organiser? 1 session	Practical support from a Professional Hoarding Practitioner or Professional Organiser? 2-5 sessions	Practical support from a Professional Hoarding Practitioner or Professional Organiser? 6-10 sessions	Practical support from a Professional Hoarding Practitioner or Professional Organiser? 11-20 sessions	Practical support from a Professional Hoarding Practitioner or Professional Organiser? More than 20 sessions	Practical support from a Professional Hoarding Practitioner or Professional Organiser? Still ongoing	Practical support from a Professional Hoarding Practitioner or Professional Organiser? N/A
Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service 1 session	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service 2-5 sessions	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service 6-10 sessions	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service 11-20 sessions	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service More than 20 sessions	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service Still ongoing	Safe and Well (Home Fire Safety) visit from the Fire & Rescue Service N/A
Attend a Hoarding Support Group?	Attend a Hoarding Support Group? 1 session	Attend a Hoarding Support Group? 2-5 sessions	Attend a Hoarding Support Group? 6-10 sessions	Attend a Hoarding Support Group? 11-20 sessions	Attend a Hoarding Support Group? More than 20 sessions	Attend a Hoarding Support Group? Still ongoing	Attend a Hoarding Support Group? N/A
Attend another Support Group?	Attend another Support Group? 1 session	Attend another Support Group? 2-5 sessions	Attend another Support Group? 6-10 sessions	Attend another Support Group? 11-20 sessions	Attend another Support Group? More than 20 sessions	Attend another Support Group? Still ongoing	Attend another Support Group? N/A
Phone a Helpline?	Phone a Helpline? 1 session	Phone a Helpline? 2-5 sessions	Phone a Helpline? 6-10 sessions	Phone a Helpline? 11-20 sessions	Phone a Helpline? More than 20 sessions	Phone a Helpline? Still ongoing	Phone a Helpline? N/A
Emotional Freedom Technique (EFT)?	Emotional Freedom Technique (EFT)? 1 session	Emotional Freedom Technique (EFT)? 2-5 sessions	Emotional Freedom Technique (EFT)? 6-10 sessions	Emotional Freedom Technique (EFT)? 11-20 sessions	Emotional Freedom Technique (EFT)? More than 20 sessions	Emotional Freedom Technique (EFT)? Still ongoing	Emotional Freedom Technique (EFT)? N/A

Other (please specify)

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* 19. How much has the therapy helped you overcome the difficulties you were experiencing that were affecting your health?

A great deal

A lot

A moderate amount

A little

Not at all

Please explain your answer

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* 20. How much has your health improved as a result of the therapy you chose?

A great deal

A lot

A moderate amount

A little

Not at all

Please explain your answer

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* 21. How much would you rate the Ice-Breaker form and recommend other people to use it to get help and support?

Poor

Fair

Good

Very good

Excellent

Poor

Fair

Good

Very good

Excellent

Please explain your answer